1. 2. 1 3. 2 4. 5. 3 6. 4 7. 5 24
8. 9. 27Gx 1/2 2.5mg 0.5mL NDC 0007-3230-02 2 NDC 0007-3230-11 10 27Gx 1/2 5mg 0.4mL NDC 0007-3232-02 2 NDC 0007-3232-11 10 27Gx 1/2 7.5mg 0.6mL NDC 0007-3234-02 2 NDC 0007-3234-11 10 27Gx 1/2 10mg 0.7mL NDC 0007-3236-02 2 NDC 0007-3236-11 10 25 C 77 F 15 30 C 59 86 F USP 25
GlaxoSmithKline Research Triangle Park, NC 27709 ARIXTRA 2005, GlaxoSkithKline. 2005 10 RL-2242 26
1.6.2. 5 1.5mg/0.3mL 2.5mg/0.5mL 2 5mg/0.4mL 7.5mg/0.6mL 10mg/0.8mL 3 2.5mg/0.5mL 7.5mg/0.6mL
1. NAME OF THE MEDICINAL PRODUCT Arixtra 2.5 mg/0.5 ml solution for injection, pre-filled syringe. 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each pre-filled syringe (0.5 ml) contains 2.5 mg of fondaparinux sodium. For excipients, see 6.1. 3. PHARMACEUTICAL FORM Solution for injection, pre-filled syringes. The solution is a clear and colourless liquid. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Prevention of Venous Thromboembolic Events (VTE) in patients undergoing major orthopaedic surgery of the lower limbs such as hip fracture, major knee surgery or hip replacement surgery. Prevention of Venous Thromboembolic Events (VTE) in patients undergoing abdominal surgery who are judged to be at high risk of thromboembolic complications, such as patients undergoing abdominal cancer surgery (see section 5.1). Prevention of Venous Thromboembolic Events (VTE) in medical patients who are judged to be at high risk for VTE and who are immobilised due to acute illness such as cardiac insufficiency and/or acute respiratory disorders, and/or acute infectious or inflammatory disease. 4.2 Posology and method of administration Patients undergoing major orthopaedic or abdominal surgery The recommended dose of Arixtra is 2.5 mg once daily administered post-operatively by subcutaneous injection. The initial dose should be given 6 hours following surgical closure provided that haemostasis has been established. Treatment should be continued until the risk of venous thrombo-embolism has diminished, usually until the patient is ambulant, at least 5 to 9 days after surgery. Experience shows that in patients undergoing hip fracture surgery, the risk of VTE continues beyond 9 days after surgery. In these patients the use of prolonged prophylaxis with Arixtra should be considered for up to an additional 24 days (see section 5.1). Medical patients who are at high risk for thromboembolic complications based on an individual risk assessment The recommended dose of Arixtra is 2.5 mg once daily administered by subcutaneous injection. A treatment duration of 6-14 days has been clinically studied in medical patients (see section 5.1). Special populations In patients undergoing major orthopaedic surgery, timing of the first Arixtra injection requires strict adherence in patients 75 years, and/or with body weight <50 kg and/or with renal impairment with creatinine clearance ranging between 20 to 50 ml/min. 1
The first Arixtra administration should be given not earlier than 6 hours following surgical closure. The injection should not be given unless haemostasis has been established. (See section 4.4). Renal impairment: Arixtra should not be used in patients with creatinine clearance < 20ml/min. In patients with creatinine clearance in the range of 20 to 30 ml/min, the use of the Arixtra 1.5 mg dose is recommended. In patients with creatinine clearance in the range of 30 to 50 ml/min, the use of the Arixtra 1.5 mg dose may be considered for short- term prophylaxis based on pharmacokinetic modelling results. For long term prophylaxis, the 1.5 mg dose should be considered as an alternative to the 2.5 mg dose. (See section 4.4). Hepatic impairment: no dosing adjustment is necessary. In patients with severe hepatic impairment, Arixtra should be used with care. (See section 4.4). Paediatric population: the safety and efficacy of Arixtra in patients under the age of 17 has not been studied. Method of administration Arixtra is administered by deep subcutaneous injection while the patient is lying down. Sites of administration should alternate between the left and the right anterolateral and left and right posterolateral abdominal wall. To avoid the loss of medicinal product when using the pre-filled syringe do not expel the air bubble from the syringe before the injection. The whole length of the needle should be inserted perpendicularly into a skin fold held between the thumb and the forefinger; the skin fold should be held throughout the injection. See section 6.6 Instructions for use and handling and disposal. 4.3 Contraindications - known hypersensitivity to fondaparinux or to any of the excipients - active clinically significant bleeding - acute bacterial endocarditis - severe renal impairment defined by creatinine clearance < 20 ml/min. 4.4 Special warnings and special precautions for use Arixtra is intended for subcutaneous use only. Do not administer intramuscularly. Haemorrhage Arixtra should be used with caution in patients who have an increased risk of haemorrhage, such as those with congenital or acquired bleeding disorders (eg. platelet count <50,000/mm 3 ), active ulcerative gastrointestinal disease and recent intracranial haemorrhage or shortly after brain, spinal or ophthalmic surgery and in special patient groups as outlined below. Agents that may enhance the risk of haemorrhage should not be administered concomitantly with fondaparinux. These agents include desirudin, fibrinolytic agents, GP IIb/IIIa receptor antagonists, heparin, heparinoids, or Low Molecular Weight Heparin (LMWH). When required, concomitant therapy with vitamin K antagonist should be administered in accordance with the information of Section 4.5. Other antiplatelet drugs (acetylsalicylic acid, dipyridamole, sulfinpyrazone, ticlopidine or clopidogrel), and NSAIDs should be used with caution. If co-administration is essential, close monitoring is necessary. Spinal / Epidural anaesthesia In patients undergoing major orthopaedic surgery, epidural or spinal haematomas that may result in long-term or permanent paralysis cannot be excluded with the concurrent use of Arixtra and 2
spinal/epidural anaesthesia or spinal puncture. The risk of these rare events may be higher with postoperative use of indwelling epidural catheters or the concomitant use of other medicinal products affecting haemostasis. Elderly patients: the elderly population is at increased risk of bleeding. As renal function is generally decreasing with age, elderly patients may show reduced elimination and increased exposure of fondaparinux. (See section 5.2). Arixtra should be used with caution in elderly patients. (See section 4.2). Low body weight: patients with body weight <50 kg are at increased risk of bleeding. Elimination of fondaparinux decreases with weight. Arixtra should be used with caution in these patients. (See section 4.2). Renal impairment: Fondaparinux is known to be mainly excreted by the kidney. Patients with creatinine clearance <50 ml/min are at increased risk of bleeding and should be treated with caution. (See section 4.2 and section 4.3). Severe hepatic impairment: dosing adjustment of Arixtra is not necessary. However, the use of Arixtra should be considered with caution because of an increased risk of bleeding due to a deficiency of coagulation factors in patients with severe hepatic impairment. (See section 4.2). Patients with Heparin Induced Thrombocytopenia Fondaparinux does not bind to platelet factor 4 and does not cross-react with sera from patients with Heparin Induced Thrombocytopenia (HIT) type II. The efficacy and safety of fondaparinux have not been formally studied in patients with HIT type II. 4.5 Interaction with other medicinal products and other forms of interaction Bleeding risk is increased with concomitant administration of Arixtra and agents that may enhance the risk of haemorrhage (See section 4.4). Oral anticoagulants (warfarin), platelet inhibitors (acetylsalicylic acid), NSAIDs (piroxicam) and digoxin did not interact with the pharmacokinetics of Arixtra. The Arixtra dose (10 mg) in the interaction studies was higher than the dose recommended for the present indications. Arixtra neither influenced the INR activity of warfarin, nor the bleeding time under acetylsalicylic acid or piroxicam treatment, nor the pharmacokinetics of digoxin at steady state. Follow-up therapy with another anticoagulant medicinal product If follow-up treatment is to be initiated with heparin or LMWH, the first injection should, as a general rule, be given one day after the last Arixtra injection. If follow up treatment with a Vitamin K antagonist is required, treatment with fondaparinux should be continued until the target INR value has been reached. 4.6 Pregnancy and lactation There are no adequate data from the use of Arixtra in pregnant women. Animal studies are insufficient with respect to effects on pregnancy, embryo/foetal development, parturition and postnatal development because of limited exposure. Arixtra should not be prescribed to pregnant women unless clearly necessary. Fondaparinux is excreted in rat milk but it is not known whether fondaparinux is excreted in human milk. Breast-feeding is not recommended during treatment with fondaparinux. Oral absorption by the child is however unlikely. 4.7 Effects on ability to drive and use machines 3
No studies on the effect on the ability to drive and to use machines have been performed. 4.8 Undesirable effects The safety of Arixtra 2.5 mg has been evaluated in 3,595 patients undergoing major orthopaedic surgery of the lower limbs treated up to 9 days, in 327 patients undergoing hip fracture surgery treated for 3 weeks following an initial prophylaxis of 1 week, 1407 patients undergoing abdominal surgery treated up to 9 days, and in 425 medical patients who are at risk for thromboembolic complications treated up to 14 days. The undesirable effects reported by the investigator as at least possibly related to Arixtra are presented within each frequency grouping (common: 1 % < 10 %; uncommon: 0.1 % < 1 %; rare: 0.01 % < 0.1 %) and system organ class by decreasing order of seriousness; these undesirable effects should be interpreted within the surgical and medical context. System organ class MedDRA Undesirable effects in patients undergoing major orthopaedic surgery of lower limbs and/or abdominal surgery Undesirable effects in medical patients Infections and infestations Blood and lymphatic system disorders Rare: post-operative wound infection Common: post-operative haemorrhage, anaemia Uncommon: bleeding (epistaxis, gastrointestinal, haemoptysis, hematuria, haematoma) thrombocytopenia, purpura, thrombocythaemia, platelet abnormal, coagulation disorder Common: bleeding (haematoma, haematuria, haemoptysis, gingival bleeding) Uncommon: anaemia Immune system disorders Rare: allergic reaction Metabolism and nutrition disorders Rare: hypokalaemia Nervous system disorders Rare: anxiety, somnolence, vertigo, dizziness, headache, confusion Vascular disorders Rare: hypotension Respiratory, thoracic and mediastinal disorders Rare: dyspnoea, coughing Uncommon: dyspnoea 4
Gastrointestinal disorders Uncommon: nausea, vomiting Rare: abdominal pain, dyspepsia, gastritis, constipation, diarrhoea Hepatobiliary disorders Uncommon: hepatic enzymes increased, hepatic function abnormal Rare: bilirubinaemia Skin and subcutaneous tissue disorders Uncommon: rash, pruritus Uncommon: rash, pruritus General disorders and administration site conditions Uncommon: oedema, oedema peripheral, fever, wound secretion Rare: chest pain, fatigue, hot flushes, leg pain, oedema genital, flushing, syncope Uncommon: chest pain In other studies or in post-marketing experience, rare cases of intracranial / intracerebral and retroperitoneal bleedings have been reported. 4.9 Overdose Arixtra doses above the recommended regimen may lead to an increased risk of bleeding. Overdose associated with bleeding complications should lead to treatment discontinuation and search for the primary cause. Initiation of appropriate therapy such as surgical haemostasis, blood replacements, fresh plasma transfusion, plasmapheresis should be considered. 5. PHARMACOLOGICAL PROPERTIES 5.1 Pharmacodynamic properties Pharmacotherapeutic group: antithrombotic agents. ATC code: B01AX05 Pharmacodynamic effects Fondaparinux is a synthetic and selective inhibitor of activated Factor X (Xa). The antithrombotic activity of fondaparinux is the result of antithrombin III (ATIII) mediated selective inhibition of Factor Xa. By binding selectively to ATIII, fondaparinux potentiates (about 300 times) the innate neutralization of Factor Xa by ATIII. Neutralisation of Factor Xa interrupts the blood coagulation cascade and inhibits both thrombin formation and thrombus development. Fondaparinux does not inactivate thrombin (activated Factor II) and has no effects on platelets. At the 2.5 mg dose, Arixtra does not affect routine coagulation tests such as activated partial thromboplastin time (aptt), activated clotting time (ACT) or prothrombin time (PT)/International Normalised Ratio (INR) tests in plasma nor bleeding time or fibrinolytic activity. Fondaparinux does not cross-react with sera from patients with heparin-induced thrombocytopaenia. Clinical studies 5
Prevention of Venous Thromboembolic Events (VTE) in patients undergoing major orthopaedic surgery of the lower limbs treated up to 9 days : the Arixtra clinical program was designed to demonstrate the efficacy of Arixtra for the prevention of venous thromboembolic events (VTE), i.e. proximal and distal deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery of the lower limbs such as hip fracture, major knee surgery or hip replacement surgery. Over 8,000 patients (hip fracture 1,711, hip replacement 5,829, major knee surgery 1,367) were studied in controlled Phase II and III clinical studies. Arixtra 2.5 mg once daily started 6-8 hours postoperatively was compared with enoxaparin 40 mg once daily started 12 hours before surgery, or 30 mg twice daily started 12-24 hours after surgery. In a pooled analysis of these studies, the recommended dose regimen of Arixtra versus enoxaparin was associated with a significant decrease (54% - 95% CI, 44 %; 63%) in the rate of VTE evaluated up to day 11 after surgery, irrespective of the type of surgery performed. The majority of endpoint events were diagnosed by a prescheduled venography and consisted mainly of distal DVT, but the incidence of proximal DVT was also significantly reduced. The incidence of symptomatic VTE, including PE was not significantly different between treatment groups. In studies versus enoxaparin 40 mg once daily started 12 hours before surgery, major bleeding was observed in 2.8% of fondaparinux patients treated with the recommended dose, compared to 2.6% with enoxaparin. Prevention of Venous Thromboembolic Events (VTE) in patients undergoing hip fracture surgery treated for up to 24 days following an initial prophylaxis of 1 week : In a randomised double-blind clinical trial, 737 patients were treated with Arixtra 2.5 mg once daily for 7 +/- 1 days following hip fracture surgery. At the end of this period, 656 patients were randomised to receive Arixtra 2.5 mg once daily or placebo for an additional 21 +/- 2 days. Fondaparinux provided a significant reduction in the overall rate of VTE compared with placebo [3 patients (1.4%) vs 77 patients (35%), respectively]. The majority (70/80) of the recorded VTE events were venographically detected non-symptomatic cases of DVT. Fondaparinux also provided a significant reduction in the rate of symptomatic VTE (DVT, and / or PE) [1 (0.3%) vs 9 (2.7%) patients, respectively] including two fatal PE reported in the placebo group. Major bleedings, all at surgical site and none fatal, were observed in 8 patients (2.4%) treated with Arixtra 2.5 mg compared to 2 (0.6%) with placebo. Prevention of Venous Thromboembolic Events (VTE) in patients undergoing abdominal surgery who are judged to be at high risk of thromboembolic complications, such as patients undergoing abdominal cancer surgery: In a double-blind clinical study, 2927 patients were randomized to receive Arixtra 2.5mg once daily or dalteparin 5000 IU once daily, with one 2500 IU preoperative injection and a first 2500 IU post-operative injection, for 7+2 days. The main sites of surgery were colonic/rectal, gastric, hepatic, cholecystectomy or other biliary. Sixty-nine percent of the patients underwent surgery for cancer. Patients under-going urological (other than kidney) or gynaecological surgery, laparoscopic surgery or vascular surgery were not included in the study. In this study, the incidence of total VTE was 4.6% (47/1027) with fondaparinux, versus 6.1%: (62/1021) with dalteparin: odds ratio reduction [95%CI] = -25.8% [-49.7%, 9.5%]. The difference in total VTE rates between the treatment groups, which was not statistically significant, was mainly due to a reduction of asymptomatic distal DVT. The incidence of symptomatic DVT was similar between treatment groups: 6 patients (0.4%) in the fondaparinux group vs 5 patients (0.3%) in the dalteparin group. In the large subgroup of patients undergoing cancer surgery (69% of the patient population), the VTE rate was 4.7% in the fondaparinux group, versus 7.7% in the dalteparin group. Major bleeding was observed in 3.4% of the patients in the fondaparinux group and in 2.4% of the dalteparin group. Prevention of Venous Thromboembolic Events (VTE) in medical patients who are at high risk for thromboembolic complications due to restricted mobility during acute illness: In a randomised double-blind clinical trial, 839 patients were treated with Arixtra 2.5 mg once daily or placebo for 6 to 14 days. This study included acutely ill medical patients, aged 60 years, expected to 6
require bed rest for at least four days, and hospitalized for congestive heart failure NYHA class III/IV and/or acute respiratory illness and/or acute infectious or inflammatory disease. Arixtra significantly reduced the overall rate of VTE compared to placebo [18 patients (5.6%) vs 34 patients (10.5%), respectively]. The majority of events were asymptomatic distal DVT. Arixtra also significantly reduced the rate of adjudicated fatal PE [0 patients (0.0%) vs 5 patients (1.2%), respectively]. Major bleedings were observed in 1 patient (0.2%) of each group. 5.2 Pharmacokinetic properties Absorption: after subcutaneous dosing, fondaparinux is completely and rapidly absorbed (absolute bioavailability 100%). Following a single subcutaneous injection of Arixtra 2.5 mg to young healthy subjects, peak plasma concentration (mean C max = 0.34 mg/l) is obtained 2 hours post-dosing. Plasma concentrations of half the mean C max values are reached 25 minutes post-dosing. In elderly healthy subjects, pharmacokinetics of fondaparinux are linear in the range of 2 to 8 mg by subcutaneous route. Following once daily dosing, steady state of plasma levels is obtained after 3 to 4 days with a 1.3-fold increase in C max and AUC. Mean (CV%) steady state pharmacokinetic parameters estimates of fondaparinux in patients undergoing hip replacement surgery receiving Arixtra 2.5 mg once daily are: C max (mg/l) - 0.39 (31%), T max (h) - 2.8 (18%) and C min (mg/l) -0.14 (56%). In hip fracture patients, associated with their increased age, fondaparinux steady state plasma concentrations are: C max (mg/l) - 0.50 (32%), C min (mg/l) - 0.19 (58%). Distribution: the distribution volume of fondaparinux is limited (7-11 litres). In vitro, fondaparinux is highly and specifically bound to antithrombin protein with a dose-dependant plasma concentration binding (98.6% to 97.0% in the concentration range from 0.5 to 2 mg/l). Fondaparinux does not bind significantly to other plasma proteins, including platelet factor 4 (PF4). Since fondaparinux does not bind significantly to plasma proteins other than ATIII, no interaction with other medicinal products by protein binding displacement are expected. Metabolism: although not fully evaluated, there is no evidence of fondaparinux metabolism and in particular no evidence for the formation of active metabolites. Fondaparinux does not inhibit CYP450s (CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1 or CYP3A4) in vitro. Thus, Arixtra is not expected to interact with other medicinal products in vivo by inhibition of CYP-mediated metabolism. Excretion/Elimination: the elimination half-life (t ½ ) is about 17 hours in healthy young subjects and about 21 hours in healthy elderly subjects. Fondaparinux is excreted to 64 77 % by the kidney as unchanged compound. Special populations: Paediatric patients: fondaparinux has not been investigated in this population. Elderly patients: renal function may decrease with age and thus, the elimination capacity for fondaparinux may be reduced in elderly. In patients >75 years undergoing orthopaedic surgery, the estimated plasma clearance was 1.2 to 1.4 times lower than in patients <65 years. Renal impairment: compared with patients with normal renal function (creatinine clearance > 80 ml/min), plasma clearance is 1.2 to 1.4 times lower in patients with mild renal impairment (creatinine clearance 50 to 80 ml/min) and on average 2 times lower in patients with moderate renal impairment (creatinine clearance 30 to 50 ml/min). In severe renal impairment (creatinine clearance < 30 ml/min), plasma clearance is approximately 5 times lower than in normal 7
renal function. Associated terminal half-life values were 29 h in moderate and 72 h in patients with severe renal impairment. Gender: no gender differences were observed after adjustment for body weight. Race: pharmacokinetic differences due to race have not been studied prospectively. However, studies performed in Asian (Japanese) healthy subjects did not reveal a different pharmacokinetic profile compared to Caucasian healthy subjects. Similarly, no plasma clearance differences were observed between black and Caucasian patients undergoing orthopaedic surgery. Body weight: plasma clearance of fondaparinux increases with body weight (9% increase per 10 kg). Hepatic impairment: fondaparinux pharmacokinetics has not been evaluated in hepatic impairment. 5.3 Preclinical safety data Preclinical data reveal no special risk for humans based on conventional studies of safety pharmacology, repeated dose toxicity, and genotoxicity. Animal studies are insufficient with respect to effects on toxicity to reproduction because of limited exposure. 6. PHARMACEUTICAL PARTICULARS 6.1 List of excipients Sodium chloride Water for injections Hydrochloric acid Sodium hydroxide 6.2 Incompatibilities In the absence of compatibility studies, Arixtra must not be mixed with other medicinal products. 6.3 Shelf life 3 years. 6.4 Special precautions for storage Do not freeze. 6.5 Nature and contents of container Arixtra pre-filled single-use syringes are made of Type I glass barrel (1 ml) affixed with a 27 gauge x 12.7 mm needle and stoppered with a bromobutyl or chlorobutyl elastomer plunger stopper. Arixtra is available in pack sizes of 2, 7, 10 and 20 pre-filled syringes with a blue automatic safety system. Not all pack sizes may be marketed. 6.6 Instructions for use and handling and disposal The subcutaneous injection is administered in the same way as with a classical syringe. Parenteral solutions should be inspected visually for particulate matter and discoloration prior to administration. 8
Instruction for self-administration is mentioned in the Package Leaflet. The needle protection system of the Arixtra pre-filled syringe has been designed with an automatic safety system to protect from needle stick injuries following injection. Any unused product or waste material should be disposed of in accordance with local requirements. 7. MARKETING AUTHORISATION HOLDER Glaxo Group Ltd Greenford Middlesex UB6 0NN United Kingdom 8. MARKETING AUTHORISATION NUMBERS EU/1/02/206/001-004 9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 21 March 2002 10. DATE OF REVISION OF THE TEXT 7 th July 2005 9
1. NAME OF THE MEDICINAL PRODUCT Arixtra 7.5 mg/0.6 ml solution for injection, pre-filled syringe. 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each pre-filled syringe contains 7.5 mg of fondaparinux sodium in 0.6 ml solution for injection. For excipients, see 6.1. 3. PHARMACEUTICAL FORM Solution for injection, pre-filled syringes. The solution is a clear and colourless to slightly yellow liquid. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Treatment of acute Deep Vein Thrombosis (DVT) and treatment of acute Pulmonary Embolism (PE), except in haemodynamically unstable patients or patients who require thrombolysis or pulmonary embolectomy. 4.2 Posology and method of administration The recommended dose of Arixtra is 7.5 mg (patients with body weight 50, 100kg) once daily administered by subcutaneous injection. For patients with body weight < 50 kg, the recommended dose is 5 mg. For patients with body weight > 100 kg, the recommended dose is 10 mg. Treatment should be continued for at least 5 days and until adequate oral anticoagulation is established (International Normalised Ratio 2 to 3). Concomitant oral anticoagulation treatment should be initiated as soon as possible and usually within 72 hours. The average duration of administration in clinical trials was 7 days and the clinical experience from treatment beyond 10 days is limited. Special populations Elderly patients: No dosing adjustment is necessary. In patients 75 years, Arixtra should be used with care, as renal function decreases with age. (See section 4.4). Renal impairment: Arixtra should be used with caution in patients with moderate renal impairment (See section 4.4). There is no experience in the subgroup of patients with both high body weight (>100 kg) and moderate renal impairment (creatinine clearance 30-50 ml/min). In this subgroup, after an initial 10 mg daily dose, a reduction of the daily dose to 7.5 mg may be considered, based on pharmacokinetic modelling (see section 4.4). Arixtra should not be used in patients with severe renal impairment (creatinine clearance < 30 ml/min) (See section 4.3). Hepatic impairment: No dosing adjustment is necessary. In patients with severe hepatic impairment, Arixtra should be used with care (see section 4.4). 10
Paediatric population: The safety and efficacy of Arixtra in patients under the age of 17 has not been studied. Method of administration Arixtra is administered by deep subcutaneous injection while the patient is lying down. Sites of administration should alternate between the left and the right anterolateral and left and right posterolateral abdominal wall. To avoid the loss of medicinal product when using the pre-filled syringe do not expel the air bubble from the syringe before the injection. The whole length of the needle should be inserted perpendicularly into a skin fold held between the thumb and the forefinger ; the skin fold should be held throughout the injection. See section 6.6 Instructions for use and handling and disposal. 4.3 Contraindications - known hypersensitivity to fondaparinux or to any of the excipients - active clinically significant bleeding - acute bacterial endocarditis - severe renal impairment (creatinine clearance < 30 ml/min). 4.4 Special warnings and special precautions for use Arixtra is intended for subcutaneous use only. Do not administer intramuscularly. There is limited experience from treatment with Arixtra in haemodynamically unstable patients and no experience in patients requiring thrombolysis, embolectomy or insertion of a vena cava filter. Haemorrhage Arixtra should be used with caution in patients who have an increased risk of haemorrhage, such as those with congenital or acquired bleeding disorders (e.g. platelet count <50,000/mm 3 ), active ulcerative gastrointestinal disease and recent intracranial haemorrhage or shortly after brain, spinal or ophthalmic surgery and in special patient groups as outlined below. As for other anticoagulants, Arixtra should be used with caution in patients who have undergone recent surgery (<3 days) and only once surgical haemostasis has been established. Agents that may enhance the risk of haemorrhage should not be administered concomitantly with fondaparinux. These agents include desirudin, fibrinolytic agents, GP IIb/IIIa receptor antagonists, heparin, heparinoids, or Low Molecular Weight Heparin (LMWH). During treatment of VTE, concomitant therapy with vitamin K antagonist should be administered in accordance with the information of Section 4.5. Other antiplatelet drugs (acetylsalicylic acid, dipyridamole, sulfinpyrazone, ticlopidine or clopidogrel), and NSAIDs should be used with caution. If co-administration is essential, close monitoring is necessary. Spinal / Epidural anaesthesia: In patients receiving Arixtra for treatment of VTE rather than prophylaxis, spinal/epidural anaesthesia in case of surgical procedures should not be used. Elderly patients: The elderly population is at increased risk of bleeding. As renal function generally decreases with age, elderly patients may show reduced elimination and increased exposure of fondaparinux (see section 5.2). Incidences of bleeding events in patients receiving the recommended regimen in the treatment of DVT or PE and aged <65 years, 65-75 and >75 years were 3.0 %, 4.5 % and 6.5 %, respectively. The corresponding incidences in patients receiving the recommended regimen of enoxaparin in the treatment of DVT were 2.5%, 3.6% and 8.3% respectively, while the incidences in patients receiving the recommended regimen of UFH in the treatment of PE were 5.5%, 6.6% and 7.4%, respectively. Arixtra should be used with caution in elderly patients (see section 4.2). 11
Low body weight: Clinical experience is limited in patients with body weight <50 kg. Arixtra should be used with caution at a daily dose of 5 mg in this population (See sections 4.2 and 5.2). Renal impairment: The risk of bleeding increases with increasing renal impairment. Fondaparinux is known to be excreted mainly by the kidney. Incidences of bleeding events in patients receiving the recommended regimen in the treatment of DVT or PE with normal renal function, mild renal impairment, moderate renal impairment and severe renal impairment were 3.0 % (34/1132), 4.4 % (32/733), 6.6% (21/318), and 14.5 % (8/55) respectively. The corresponding incidences in patients receiving the recommended regimen of enoxaparin in the treatment of DVT were 2.3% (13/559), 4.6% (17/368), 9.7% (14/145) and 11.1% (2/18) respectively, and in patients receiving the recommended regimen of unfractionated heparin in the treatment of PE were 6.9% (36/523), 3.1% (11/352), 11.1% (18/162) and 10.7% (3/28), respectively. Arixtra is contra-indicated in severe renal impairment (creatinine clearance <30 ml/min) and should be used with caution in patients with moderate renal impairment (creatinine clearance 30-50 ml/min). The duration of treatment should not exceed that evaluated during clinical trial (mean 7 days) (See sections 4.2, 4.3 and 5.2). There is no experience in the subgroup of patients with both high body weight (>100 kg) and moderate renal impairment (creatinine clearance 30-50 ml/min). Arixtra should be used with care in these patients. After an initial 10 mg daily dose, a reduction of the daily dose to 7.5 mg may be considered, based on pharmacokinetic modelling (see section 4.2). Severe hepatic impairment: The use of Arixtra should be considered with caution because of an increased risk of bleeding due to a deficiency of coagulation factors in patients with severe hepatic impairment. (See section 4.2). Patients with Heparin Induced Thrombocytopenia: Fondaparinux does not bind to platelet factor 4 and does not cross-react with sera from patients with Heparin Induced Thrombocytopenia (HIT) type II. The efficacy and safety of fondaparinux have not been formally studied in patients with HIT type II. 4.5 Interaction with other medicinal products and other forms of interaction Bleeding risk is increased with concomitant administration of Arixtra and agents that may enhance the risk of haemorrhage (See section 4.4). In clinical studies performed with Arixtra, oral anticoagulants (warfarin) did not interact with the pharmacokinetics of Arixtra ; at the 10 mg dose used in the interaction studies, Arixtra did not influence the anticoagulation monitoring (INR) activity of warfarin. Platelet inhibitors (acetylsalicylic acid), NSAIDs (piroxicam) and digoxin did not interact with the pharmacokinetics of Arixtra. At the 10 mg dose used in the interaction studies, Arixtra did not influence the bleeding time under acetylsalicylic acid or piroxicam treatment, nor the pharmacokinetics of digoxin at steady state. 4.6 Pregnancy and lactation No clinical data on exposed pregnancies are available. Animal studies are insufficient with respect to effects on pregnancy, embryo/foetal development, parturition and postnatal development because of limited exposure. Arixtra should not be prescribed to pregnant women unless clearly necessary. Fondaparinux is excreted in rat milk but it is not known whether fondaparinux is excreted in human milk. Breast-feeding is not recommended during treatment with fondaparinux. Oral absorption by the child is however unlikely. 12
4.7 Effects on ability to drive and use machines No studies on the effect on the ability to drive and to use machines have been performed. 4.8 Undesirable effects The safety of Arixtra has been evaluated in 2,517 patients treated for Venous Thrombo-Embolism and treated with fondaparinux for an average of 7 days. The most common adverse reactions were bleeding complications (See section 4.4). The undesirable effects reported by the investigator as at least possibly related to Arixtra are presented within each frequency grouping (common: 1 % < 10 %; uncommon: 0.1 % < 1 %; rare: 0.01 % < 0.1 %) and system organ class by decreasing order of seriousness. System organ class Undesirable effects (1) Red blood cells disorders Uncommon: anaemia Platelet, bleeding and clotting disorders Common: bleeding (gastrointestinal, hematuria, hematoma, epistaxis, haemoptysis, utero-vaginal haemorrhage, haemarthrosis, ocular, purpura, bruise) Uncommon: thrombocytopaenia Central and peripheral nervous system disorders Gastro-intestinal system disorders Liver and biliary disorders Skin and appendage disorders Body as a whole- general disorders Metabolic and nutritional disorders Rare: other bleeding (hepatic, retroperitoneal, intracranial/intracerebral), thrombocythaemia Uncommon: headache Rare: dizziness Uncommon: nausea, vomiting Uncommon: abnormal liver function Rare: rash erythematous, reaction at injection site Uncommon: pain, oedema Rare: allergic reaction Rare: non-protein-nitrogen (Npn) (2) increased (1) isolated AEs have not been considered except if they were medically relevant. (2) Npn stands for non-protein-nitrogen such as urea, uric acid, amino acid, etc... 4.9 Overdose Arixtra doses above the recommended regimen may lead to an increased risk of bleeding. There is no known antidote to fondaparinux. Overdose associated with bleeding complications should lead to treatment discontinuation and search for the primary cause. Initiation of appropriate therapy such as surgical haemostasis, blood replacements, fresh plasma transfusion, plasmapheresis should be considered. 5. PHARMACOLOGICAL PROPERTIES 5.1 Pharmacodynamic properties Pharmacotherapeutic group: antithrombotic agents. Proposed ATC code: B01AX05 13
Pharmacodynamic effects Fondaparinux is a synthetic and selective inhibitor of activated Factor X (Xa). The antithrombotic activity of fondaparinux is the result of antithrombin III (antithrombin) mediated selective inhibition of Factor Xa. By binding selectively to antithrombin, fondaparinux potentiates (about 300 times) the innate neutralization of Factor Xa by antithrombin. Neutralisation of Factor Xa interrupts the blood coagulation cascade and inhibits both thrombin formation and thrombus development. Fondaparinux does not inactivate thrombin (activated Factor II) and has no effects on platelets. At the doses used for treatment, Arixtra does not, to a clinically relevant extent, affect routine coagulation tests such as activated partial thromboplastin time (aptt), activated clotting time (ACT) or prothrombin time (PT)/International Normalised Ratio (INR) tests in plasma nor bleeding time or fibrinolytic activity. At higher doses, moderate changes in aptt can occur. At the 10 mg dose used in interaction studies, Arixtra did not significantly influence the anticoagulation activity (INR) of warfarin. Fondaparinux does not cross-react with sera from patients with heparin-induced thrombocytopaenia. Clinical studies The Arixtra clinical program in treatment of Venous Thromboembolism was designed to demonstrate the efficacy of Arixtra for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Over 4874 patients were studied in controlled Phase II and III clinical studies. Treatment of Deep Venous Thrombosis In a randomised, double-blind, clinical trial in patients with a confirmed diagnosis of acute symptomatic DVT, Arixtra 5 mg (body weight < 50 kg), 7.5 mg (body weight 50 kg, 100 kg) or 10 mg (body weight >100 kg) SC once daily was compared to enoxaparin sodium 1 mg/kg SC twice daily. A total of 2192 patients were treated ; for both groups, patients were treated for at least 5 days and up to 26 days (mean 7 days). Both treatment groups received Vitamin K antagonist therapy usually initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days, with regular dose adjustments to achieve an INR of 2-3. The primary efficacy endpoint was the composite of confirmed symptomatic recurrent non-fatal VTE and fatal VTE reported up to Day 97. Treatment with Arixtra was demonstrated to be non-inferior to enoxaparin (VTE rates 3.9% and 4.1%, respectively). Major bleeding during the initial treatment period was observed in 1.1% of fondaparinux patients, compared to 1.2% with enoxaparin. Treatment of Pulmonary Embolism A randomised, open-label, clinical trial was conducted in patients with acute symptomatic PE. The diagnosis was confirmed by objective testing (lung scan, pulmonary angiography or spiral CT scan). Patients who required thrombolysis or embolectomy or vena cava filter were excluded. Randomised patients could have been pre-treated with UFH during the screening phase but patients treated for more than 24 hours with therapeutic dose of anticoagulant or with uncontrolled hypertension were excluded. Arixtra 5 mg (body weight < 50 kg), 7.5 mg (body weight 50kg, 100 kg) or 10 mg (body weight >100 kg) SC once daily was compared to unfractionated heparin IV bolus (5000 IU) followed by a continuous IV infusion adjusted to maintain 1.5 2.5 times aptt control value.. A total of 2184 patients were treated; for both groups, patients were treated for at least 5 days and up to 22 days (mean 7 days). Both treatment groups received Vitamin K antagonist therapy usually initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days, with regular dose adjustments to achieve an INR of 2-3. The primary efficacy endpoint was the composite of confirmed symptomatic recurrent non-fatal VTE and fatal VTE reported up to Day 97. Treatment with Arixtra was demonstrated to be non-inferior to unfractionated heparin (VTE rates 3.8% and 5.0%, respectively). Major bleeding during the initial treatment period was observed in 1.3% of fondaparinux patients, compared to 1.1% with unfractionated heparin. 14
5.2 Pharmacokinetic properties The pharmacokinetics of fondaparinux sodium are derived from fondaparinux plasma concentrations quantified via anti factor Xa activity. Only fondaparinux can be used to calibrate the anti-xa assay (the international standards of heparin or LMWH are not appropriate for this use). As a result, the concentration of fondaparinux is expressed as milligrams (mg). Absorption: after subcutaneous dosing, fondaparinux is completely and rapidly absorbed (absolute bioavailability 100%). Following a single subcutaneous injection of Arixtra 2.5 mg to young healthy subjects, peak plasma concentration (mean C max = 0.34 mg/l) is obtained 2 hours post-dosing. Plasma concentrations of half the mean C max values are reached 25 minutes post-dosing. In elderly healthy subjects, pharmacokinetics of fondaparinux is linear in the range of 2 to 8 mg by subcutaneous route. Following once daily dosing, steady state of plasma levels is obtained after 3 to 4 days with a 1.3-fold increase in C max and AUC. Mean (CV%) steady state pharmacokinetic parameters estimates of fondaparinux in patients undergoing hip replacement surgery receiving Arixtra 2.5 mg once daily are: C max (mg/l) - 0.39 (31%), T max (h) - 2.8 (18%) and C min (mg/l) -0.14 (56%). In hip fracture patients, associated with their increased age, fondaparinux steady state plasma concentrations are: C max (mg/l) - 0.50 (32%), C min (mg/l) - 0.19 (58%). In DVT and PE treatment, patients receiving Arixtra 5 mg (body weight <50 kg), 7.5 mg (body weight 50-100 kg inclusive) and 10 mg (body weight >100 kg) once daily, the body weight-adjusted doses provide similar exposure across all body weight categories. The mean (CV%) steady state pharmacokinetic parameters estimates of fondaparinux in patients with VTE receiving the fondaparinux proposed dose regimen once daily are: C max (mg/l) - 1.41 (23 %), T max (h) 2.4 (8%) and C min (mg/l) -0.52 (45 %). The associated 5th and 95th percentiles are, respectively, 0.97 and 1.92 for C max (mg/l), and 0.24 and 0.95 for C min (mg/l). Distribution: the distribution volume of fondaparinux is limited (7-11 litres). In vitro, fondaparinux is highly and specifically bound to antithrombin protein with a dose-dependant plasma concentration binding (98.6% to 97.0% in the concentration range from 0.5 to 2 mg/l). Fondaparinux does not bind significantly to other plasma proteins, including platelet factor 4 (PF4). Since fondaparinux does not bind significantly to plasma proteins other than antithrombin, no interaction with other medicinal products by protein binding displacement are expected. Metabolism: although not fully evaluated, there is no evidence of fondaparinux metabolism and in particular no evidence for the formation of active metabolites. Fondaparinux does not inhibit CYP450s (CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1 or CYP3A4) in vitro. Thus, Arixtra is not expected to interact with other medicinal products in vivo by inhibition of CYP-mediated metabolism. Excretion/Elimination: the elimination half-life (t ½ ) is about 17 hours in healthy young subjects and about 21 hours in healthy elderly subjects. Fondaparinux is excreted to 64 77 % by the kidney as unchanged compound. Special populations: Paediatric patients: fondaparinux has not been investigated in this population. Elderly patients: renal function may decrease with age and thus, the elimination capacity for fondaparinux may be reduced in elderly. In patients >75 years undergoing orthopaedic surgery and receiving Arixtra 2.5 mg once daily, the estimated plasma clearance was 1.2 to 1.4 times lower than in patients <65 years. A similar pattern is observed in DVT and PE treatment patients. 15
Renal impairment: compared with patients with normal renal function (creatinine clearance > 80 ml/min) undergoing orthopaedic surgery and receiving Arixtra 2.5 mg once daily, plasma clearance is 1.2 to 1.4 times lower in patients with mild renal impairment (creatinine clearance 50 to 80 ml/min) and on average 2 times lower in patients with moderate renal impairment (creatinine clearance 30 to 50 ml/min). In severe renal impairment (creatinine clearance <30 ml/min), plasma clearance is approximately 5 times lower than in normal renal function. Associated terminal half-life values were 29 h in moderate and 72 h in patients with severe renal impairment. A similar pattern is observed in DVT and PE treatment patients. Body weight: plasma clearance of fondaparinux increases with body weight (9% increase per 10 kg). Gender: no gender differences were observed after adjustment for body weight. Race: pharmacokinetic differences due to race have not been studied prospectively. However, studies performed in Asian (Japanese) healthy subjects did not reveal a different pharmacokinetic profile compared to Caucasian healthy subjects. Similarly, no plasma clearance differences were observed between black and Caucasian patients undergoing orthopaedic surgery. Hepatic impairment: fondaparinux pharmacokinetics has not been evaluated in hepatic impairment. 5.3 Preclinical safety data Preclinical data reveal no special risk for humans based on conventional studies of safety pharmacology and genotoxicity. The repeated dose and reproduction toxicity studies did not reveal any special risk but did not provide adequate documentation of safety margins due to limited exposure in the animal species. 6. PHARMACEUTICAL PARTICULARS 6.1 List of excipients Sodium chloride Water for injections Hydrochloric acid Sodium hydroxide 6.2 Incompatibilities In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products. 6.3 Shelf life 3 years 6.4 Special precautions for storage Do not freeze. 6.5 Nature and contents of container Arixtra pre-filled single-use syringes are made of Type I glass barrel (1 ml) affixed with a 27 gauge x 12.7 mm needle and stoppered with a chlorobutyl elastomer plunger stopper. 16
Arixtra 7.5 mg/0.6 ml is available in pack sizes of 2, 7, 10 and 20 pre-filled syringes with a magenta automatic safety system. Not all pack sizes may be marketed. 6.6 Instructions for use and handling and disposal The subcutaneous injection is administered in the same way as with a classical syringe. Parenteral solutions should be inspected visually for particulate matter and discoloration prior to administration. Instruction for self-administration is mentioned in the Package Leaflet. The Arixtra pre-filled syringe has been designed with an automatic needle protection system to prevent needle stick injuries following injection. Any unused product or waste material should be disposed of in accordance with local requirements. This medicinal product is for single use only. 7. MARKETING AUTHORISATION HOLDER Glaxo Group Ltd Greenford Middlesex UB6 0NN United Kingdom 8. MARKETING AUTHORISATION NUMBERS EU/1/02/206/012-014, 019 9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 21 March 2002 10. DATE OF REVISION OF THE TEXT 7 February 2006 17
1. 2.5 mg/0.5 ml 2. 0.5 ml 2.5mg 6.1 3. 4. 4.1 VTE VTE 5.1 VTE VTE 4.2 1 1 2.5 mg 6 5 9 VTE 9 24 5.1 1 1 2.5mg 6 14 5.1 75 50kg 20 50 ml/min 1
6 4.4 20 ml/min 20 30 ml/min 1.5mg 30 50 ml/min 1.5mg 2.5mg 1.5mg 4.4 4.4 17 6.6 4.3 20 ml/min 4.4 50,000/mm 3 desirudin GP b/ a LMWH 4.5 K sulfinpyrazone clopidogrel 2
5.2 4.2 50kg 4.2 50mL/min 4.2 4.3 4.2 4 HIT HIT 4.5 4.4 10mg INR LMWH K INR 4.6 3
4.7 4.8 9 3595 1 3 327 9 1407 14 425 2.5mg 1% 10% 0.1% 1% 0.01% 0.1% 4
4.9 5. 5.1 ATC B01AX05 a a AT a AT AT a 300 a 2.5mg aptt ACT PT / INR 9 VTE 5
VTE DVT PE 8000 1711 5829 1367 1 1 2.5mg 6 8 1 1 enoxaparin 40mg 12 1 2 enoxaparin 30mg 12 24 11 VTE enoxaparin 54%-95% 44% 63% DVT DVT PE VTE 12 1 1 enoxaparin 40mg 2.8% enoxaparin 2.6% Major bleeding 1 24 VTE 737 2.5mg 1 1 7±1 656 2.5mg 1 1 21±2 VTE 3 1.4% 77 35% VTE 70/80 DVT 2 PE VTE DVT PE 1 0.3% 9 2.7% Major bleeding 2 0.6% 2.5mg 8 2.4% VTE 2927 2.5mg 1 1 5000 1 1 1 2500 7 2 69% VTE 4.6% 47/1027 6.1% 62/1021-25.8% 95% -49.7%, 9.5% VTE DVT DVT 6 0.4% 5 0.3% 69% VTE 7.7% 4.7% Major bleeding 3.4% 2.4% 6
839 2.5mg1 1 6 14 60 4 NYHA VTE 18 5.6% 34 10.5% DVT PE 0 0.0% 5 1.2% Major bleeding 1 0.2% 5.2 100% 2.5mg 2 C max =0.34 mg/l C max 1/2 25 2 8mg 1 1 3 4 C max AUC 1.3 2.5mg 1 1 CV% C max : 0.39 mg/l 31% T max : 2.8 18% C min : 0.14 mg/l 56% C max : 0.50 mg/l 32% C min : 0.19 mg/l 58% 7 11 in vitro 0.5 2 mg/l 98.6% 97.0% 4 PF4 AT in vitro CYP450 CYP1A2 CYP2A6 CYP2C9 CYP2C19 CYP2D6 CYP2E1 CYP3A4 CYP t 1/2 17 21 64 77% 75 65 1/1.2 1/1.4 7
50 80 ml/min 80 ml/min 1/1.2 1/1.4 30 50 ml/min 1/2 30 ml/min 1/5 29 72 10kg 9% 5.3 6. 6.1 6.2 6.3 3 6.4 6.5 27G 12.7mm I 1mL 8
2 7 10 20 6.6 7. Greenford Middlesex UB6 0NN United Kingdom 8. EU/1/02/206/001-004 9. 2002 3 21 10. 2005 7 7 9
1. 7.5 mg/0.6 ml 2. 0.6 ml 7.5mg 6.1 3. 4. 4.1 DVT PE 4.2 1 1 7.5 mg 50kg 100kg 50kg 5mg 100kg 10mg 5 2 3 72 7 10 75 4.4 4.4 100kg 30 50mL/min 10mg 1 7.5mg 4.4 30mL/min 4.3 4.4 17 10
6.6 4.3 30 ml/min 4.4 50,000/mm 3 3 desirudin GP b/ a LMWH VTE 4.5 K sulfinpyrazone clopidogrel VTE 5.2 DVT PE 65 65 75 75 3.0% 4.5% 6.5% enoxaparin DVT 2.5% 3.6% 8.3% PE 5.5% 6.6% 7.4% 4.2 50kg 1 5mg 4.2 5.2 11
DVT PE 3.0% 34/1132 4.4% 32/733 6.6% 21/318 14.5% 8/55 DVT enoxaparin 2.3% 13/559 4.6% 17/368 9.7% 14/145 11.1% 2/18 PE 6.9% 36/523 3.1% 11/352 11.1% 18/162 10.7% 3/28 30mL/min 30 50mL/min 7 4.2 4.3 5.2 100kg 30 50mL/min 10mg 1 7.5mg 4.2 4.2 4 HIT HIT 4.5 4.4 10mg INR 10mg 4.6 12
4.7 4.8 2517 7 4.4 1% 10% 0.1% 1% 0.01% 0.1% 1 2 (1) (2) 4.9 5. 5.1 ATC B01AX05 13
a a AT a AT AT a 300 a aptt ACT PT / INR aptt 10mg INR DVT PE 4874 DVT 5mg 50kg 7.5mg 50kg 100kg 10mg 100kg 1 1 enoxaparin sodium 1mg/kg1 2 2192 5 26 7 K 72 INR2-3 90±7 97 VTE VTE enoxaparin VTE 3.9% 4.1% Major bleeding enoxaparin 1.2% 1.1% PE CT 24 5mg 50kg 7.5mg 50kg 100kg 10mg 100kg 1 1 aptt 14
1.5-2.5 5000 2184 5 22 7 K 72 INR2-3 90±7 97 VTE VTE VTE 3.8% 5.0% Major bleeding 1.1% 1.3% 5.2 a a mg 100% 2.5mg 2 C max =0.34 mg/l C max 1/2 25 2 8mg 1 1 3 4 C max AUC 1.3 2.5mg 1 1 CV% C max : 0.39 mg/l 31% T max : 2.8 18% C min : 0.14 mg/l 56% C max : 0.50 mg/l 32% C min : 0.19 mg/l 58% DVT PE 5mg 50kg 7.5mg 50kg 100kg 10mg 100kg 1 1 1 1 VTE CV% C max : 1.41 mg/l 23% T max : 2.4 8% C min : 0.52 mg/l 45% 5 95 C max mg/l 0.97 1.92 C min mg/l 0.24 0.95 7 11 in vitro 0.5 2 mg/l 98.6% 97.0% 4 PF4 AT 15